Long-term patency in cerebral revascularization surgery: an analysis of a consecutive series of 430 bypasses

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OBJECTIVE

Large cohort analysis concerning intracerebral bypass patency in patients with long-term follow-up (FU) results is rarely reported in the literature. The authors analyzed the long-term patency of extracranial-to-intracranial (EC-IC) and intracranial-to-intracranial (IC-IC) bypass procedures.

METHODS

All intracranial bypass procedures performed between 1997 and 2017 by a single surgeon were screened. Patients with postoperative imaging (CT angiography, MR angiography, or catheter angiography) were included and grouped into immediate (< 7 days), short-term (7 days–1 year), and long-term (> 1 year) FU groups. Data on patient demographics, bypass type, interposition graft type, bypass indication, and radiological patency were collected and analyzed with univariate and multivariate (adjusted multiple regression) models.

RESULTS

In total, 430 consecutive bypass procedures were performed during the study period (FU time [mean ± SD] 0.9 ± 2.2 years, range 0–17 years). Twelve cases were occluded at FU imaging, resulting in an overall cumulative patency rate of 97%. All bypass occlusions occurred within a week of revascularization. All patients in the short-term FU group (n = 76, mean FU time 0.3 ± 0.3 years) and long-term FU group (n = 89, mean FU time 4.1 ± 3.5 years) had patent bypasses at last FU. Patients who presented with aneurysms had a lower rate of patency than those with moyamoya disease or chronic vessel occlusion (p = 0.029). Low-flow bypasses had a significantly higher patency rate than high-flow bypasses (p = 0.033). In addition, bypasses with one anastomosis site compared to two anastomosis sites showed a significantly higher bypass patency (p = 0.005). No differences were seen in the patency rate among different grafts, single versus bilateral, or between EC-IC and IC-IC bypasses.

CONCLUSIONS

The overall bypass patency of 97% indicates a high likelihood of success with microsurgical revascularization. Surgical indication (ischemia), low-flow bypass, and number of anastomosis (one site) were associated with higher patency rates. EC-IC and IC-IC bypasses have comparable patency rates, supporting the use of intracranial reconstructive techniques. Bypasses that remain patent 1 week postoperatively and have the opportunity to mature have a high likelihood of remaining patent in the long term. In experienced hands, cerebral revascularization is a durable treatment option with high patency rates.

ABBREVIATIONS ACA = anterior cerebral artery; EC = extracranial; FU = follow-up; IC = intracranial; ICA = internal carotid artery; MCA = middle cerebral artery; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; RAG = radial artery graft; SCA = superior cerebellar artery; STA = superficial temporal artery.

Article Information

Correspondence Michael T. Lawton: Barrow Neurological Institute, Phoenix, AZ. michael.lawton@barrowbrainandspine.com.

INCLUDE WHEN CITING Published online August 24, 2018; DOI: 10.3171/2018.3.JNS172158.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Cumulative patency of 430 cases of cerebral revascularization over 20 years.

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    This 40-year-old man presented with a left cranial nerve VI palsy due to compression from a left fusiform ICA aneurysm (arrow, A and B). After patient consent and an Allen test showing a competent palmar arch, an ICA-RAG-M2 MCA bypass was performed through a left pterional craniotomy. The MCA was brought into full view with a wide Sylvian fissure split, and the frontal trunk of the MCA bifurcation was selected for the bypass after the RAG was harvested from the left forearm. Temporary clips were placed on the recipient MCA after first placing the patient in barbiturate-induced electroencephalogram burst suppression, and the anastomosis was completed with running 9-0 monofilament nylon sutures. The first suture line was inspected intraluminally (C) and the second suture line was then sewn in similar fashion (D). The proximal end-to-end anastomosis was completed to the cervical ICA and flow was initiated in the bypass (E). There was good pulsation in the graft, and an indocyanine green angiogram confirmed patency (F). Postoperative angiography showed patency of the bypass with filling of the MCA territory through the bypass and occlusion of the ICA aneurysm (left ICA angiogram, anteroposterior [G] and lateral [H] views). The patient recovered well from surgery with no neurological deficits. Five-year FU catheter angiography confirmed patency of the bypass (left ICA angiogram, anteroposterior [I] and lateral [J] views). This case demonstrates maturation of a high-flow bypass at late FU.

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    This 66-year-old woman presented with seizures due to a giant left M1 aneurysm (left ICA angiogram, anteroposterior [A] and lateral [B] views). After patient consent and a failed Allen test, a left external carotid artery–saphenous vein graft–M2 segment bypass was performed through a pterional craniotomy. The MCA aneurysm was in full view after a wide Sylvian fissure split, and a M2 branch was selected for the bypass (C). The saphenous vein was harvested from her leg and had significant varicosities. The first suture line was completed with running continuous 9-0 sutures on the back wall first, followed by the same technique on the front wall (D and E). Note the size discrepancy between the varicose vein graft and the M2 recipient. The graft was tunneled and connected to the external carotid artery with an end-to-end anastomosis using a double-armed Prolene suture. There was good pulsation in the vein graft (F). The aneurysm had lenticulostriate arteries originating from its walls, and therefore only a proximal occlusion was performed using a permanent clip placement on the M1 segment just as it entered into the aneurysm (G). Doppler flow studies confirmed good perfusion in the distal vessels and in the bypass graft with no changes in the motor evoked or somatosensory evoked potential neurophysiological monitoring. Catheter angiography on postoperative day 1 showed early occlusion of the EC-IC high-flow bypass (left ICA angiogram, anteroposterior [H] and lateral [I] views). The patient experienced an MCA stroke (J) with aphasia and right-sided hemiparesis, as seen on her axial CT scan. This case demonstrates an unexpected bypass occlusion resulting from venous varicosities in the graft and significant caliber mismatch between donor and recipient.

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